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, <br /> .., , __ CllyofEverattUsoOnly i I <br /> � �ECEIV�� � � <br /> � TORT CLAI,M FORM <br /> Pcu.07/C3 ��" O � ���� <br /> Pursuant tn Chapter 9.96 0( thc Revised Co�e of t�ashin9ton (RQN), �jTY OF EVE�E�'x ' <br /> this form i5 for fl!ing a tort claim against Hte City o' Ever2tt. Some o( ! 1- � <br /> the information requesled on this form R required by RCIN 4.96.020 CI� CIQt'lf. __ <br /> and may be subject to public discfosure. The Ci[� Clerk fs the City's c�p•cierk ci�im vo. " ' <br /> designated agent for the purpose of receiving clalms. C/alm forms /�� <br /> cannot be submiked e%Rronlca/ty(via e•mai/or iax). - �(' � � � �. - , -,. I <br /> I <br /> PLEAS�TYPEOR:PRIfJ�CI_EA�tLY2N;INK. , _ . , • - : - `�i <br /> i <br /> Mall or defiver orlgfnal signed claim form to; OKce � �he City Clerk <br /> tity ot:':ereK ' <br /> Business Hours: 2930 Wetmore Ave.,Ste. 1-A <br /> Mon.-Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 � <br /> Clased on city holidays � <br /> � <br /> CLAIMANTINFORMATION: <br /> 1.C�aimant's name: � <br /> fasiiu�mc � `c%�1��i�sf � n�F'rddl.^ � Dafeofbirth(mrrl/Cd/yyyyJ <br /> 2.Current residential address: . �7�1 �uC�!_.�2 f'1�� �� I.;'�?-� c' ZO � <br /> 3.Piailing address(if differen[): :�� C��� �`l % 3��i ' %i�-�,�7 <br /> q.Residentlal address at the lime o(the inciden.(if difTcrcnt from current address): <br /> .�Ir1�f <br /> S.Clalmanl'slelephoneaumG�r. I_��r7 '-5��--U_���G/-�G�Z� . .. _ . <br /> �.Ht�nre��� � � Ccll � � 8usinecs � <br /> 6.Claimant's e•mall address `��'?l= 1J/r"TC}L�C7#�t'yVt%G-'92� (,{�-il� _________ _ <br /> iNCIDENT INFORMATION: <br /> 7. Dale of InddenL ._- )`��' 'T1me: , 1�U� ❑a.m. ��i, .m. (check one) <br /> (mm/dd/YY1'Y) ,_--} --�- � . <br /> 6.If the Inddent occurted over a pedod of tlmq date of first and la,t occurrences: � <br /> fwm: � Lme: fl a.m. O p.m.(check one) to Time: 0 a.m. I7 p.m.(check one) '. <br /> ('mm)dd/yvyyS n (mnJed/vyyr) <br /> 9.Lowdan of Intfdent: ,'t" �e f lui7���S� '��� �-�rT ��/�� �V(��I� ��1�'�{J <br /> 5!aie and m nry Oty,�ifapp,5cab'e P/acr where ocr�rrM <br /> 10. If the incide�SC�rred on a strcet or hlghv.�ay: <br /> ��� _ ""'-- <br /> Name o! t a A;'ghway At(/m intcrs^:fia;nvdM1 n�nea;est infer5cttfn0 s7eM <br /> � <br /> � <br /> I <br />